WITH ANSWERS (100% CORRECT)
A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend
social activities. The spouse does the grocery shopping because the patient cannot remember what to buy.
Which nursing diagnosis applies at this time?
A. Risk for injury
B. Impaired memory
C. Self-care deficit
D. Caregiver role strain
ANS: B
Which patients meet criteria for hospice services? (Select all that apply.)
A. A 92-year-old diagnosed with acute pneumonia and late-stage Alzheimer’s disease
B. A 54-year-old diagnosed with glioblastoma and life expectancy of 8 to 10 weeks
C. A 16-year-old with type 1 diabetes, multiple infections, and substance abuse
D. A 74-year-old newly diagnosed with chronic obstructive pulmonary disease (COPD) and life
expectancy of 2 years
E. A 36-year-old diagnosed with multiple sclerosis complicated by major depressive disorder and pain
associated with muscle spasms
ANS: A, B
An older adult drove to a nearby store but was unable to remember how to get home or state an address.
When police took the person home, the spouse reported frequent wandering into neighbors’ homes.
Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident?
A. 1 (mild)
B. 2 (moderate)
C. 3 (moderate to severe)
D. 4 (late)
ANS: B
A nurse should anticipate that which symptoms of Alzheimer disease will become apparent asthe disease
progresses from moderate to severe to late stage? Select all that apply.
A. Agraphia
B. Hyperorality
C. Fine motor tremors
D. Hyper metamorphosis
E. Improvement of memory
ANS: A, B, D
When making a distinction as to whether an elderly client is experiencing confusion related
to delirium or another problem, what information would be of particular value?
A. Evidence of spasticity or flaccidity
B. The client’s level of motor activity
C. Medications the client has recently taken
D. Level of preoccupation with somatic symptoms
ANS: C
,Which assessment findings would the nurse expect in a client experiencing delirium? (Select
all that apply.)
A. Impaired level of consciousness
B. Disorientation to place, time
C. Wandering attention
D. Apathy
E. Agnosia
ANS: A, B, C
When making a distinction asto whether a patient is experiencing confusion related to
depression or dementia, what information would be most important for the nurse to
consider?
A. The patient with dementia is persistently angry and hostile.
B. Early morning agitation and hyperactivity occur in dementia.
C. Confusion seems to worsen at night when dementia is present.
D. A patient who is depressed is constantly preoccupied with somatic symptoms.
ANS: C
Which intervention is appropriate to use for patients diagnosed with either delirium or dementia?
A. Speak in a loud, firm voice.
B. Touch the patient before speaking.
C. Reintroduce the health care worker at each contact.
D. When the patient becomes aggressive, use physical restraint instead of medication.
ANS: C
A hospitalized patient experiencing delirium misinterpret reality, and a patient diagnosed with dementia
wanders about the home. Which outcome is the priority in both scenarios? Each patient will:
A. remain safe in the environment.
B. participate actively in self-care.
C. communicate verbally.
D. acknowledge reality.
ANS: A
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes
trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse
anticipate the health care provider will prescribe?
A. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
B. Phenothiazine, such as thioridazine (Mellaril)
C. Benzodiazepine, such as lorazepam (Ativan)
D. Narcotic analgesic, such as morphine
ANS: C
Which nursing diagnoses are most applicable for a client diagnosed with severe late-stage Alzheimer’s
disease? (Select all that apply.)
A. Acute confusion
B. Anticipatory grieving
, C. Urinary incontinence
D. Disturbed sleep pattern
E. Risk for caregiver role strain
ANS: C, D, E
An adult diagnosed with schizophrenia lives with elderly parents. The client was recently hospitalized with
acute psychosis. One parent is very anxious, and the other is ill because of the stress. Which nursing diagnosis
is most applicable to this scenario?
A. Ineffective family coping related to parental role conflict
B. Caregiver role strain related to the stress of chronic illness
C. Impaired parenting related to client’s repeated hospitalizations
D. Interrupted family processes related to relapse of acute psychosis
ANS: B
Which client would be most appropriate to refer for assertive community treatment (ACT)?
A. One diagnosed with a phobic fear of crowded places.
B. One who experienced a single episode of major depressive disorder.
C. One who experienced a catastrophic reaction to a tornado in the community.
D. One diagnosed with schizophrenia who had four hospitalizations in the past year.
ANS: D
The sibling of a client who was diagnosed with a serious mental illness (SMI) asks why a case manager has
been assigned. Which nurse’s reply best cites the major advantage of the use of case management?
A. “The case manager can modify traditional psychotherapy for homeless clients so that it is more
flexible.”
B. “Case managers coordinate services and help with accessing them, making sure the client’s needs are
met.”
C. “The case manager can focus on social skills training and esteem building in the real world where the
client lives.”
D. “Having a case manager has been shown to reduce hospitalizations, which prevents disruption and
saves money.”
ANS: B
For clients diagnosed with serious mental illness (SMI), what is the major advantage of case
management?
a. The case manager can modify traditional psychotherapy.
b. With one coordinator of services, resources can be more efficiently used.
c. The case manager can focus on social skills training and esteem building.
d. Case managers bring groups of clients together to discuss common problems.
ANS: B
A client diagnosed with a serious mental illness (SMI) life independently and attends a psychosocial
rehabilitation program. The client presents at the emergency department seeking hospitalization. The client
has no acute symptoms but says, “I have no money to pay my rent or refill my prescription.” What is the
nurse’s best action?